What is the recommended management for facial lacerations?

Management of Facial Lacerations

Facial lacerations should be managed with copious irrigation, cautious debridement, preemptive antibiotics, and primary wound closure, which is an exception to the general rule against primary closure of contaminated wounds. 1, 2

Initial Assessment and Preparation

• Thoroughly cleanse the wound with sterile saline irrigation under pressure to remove debris and contaminants 3
• Perform cautious debridement of devitalized tissue without enlarging the wound or impairing skin closure 2
• Consider radiographic examination if there is concern for foreign bodies or underlying fractures 3
• Ensure tetanus prophylaxis is current:
  • Administer tetanus toxoid if >5 years since last dose for dirty wounds or >10 years for clean wounds
  • Tdap is preferred over Td if not previously given 2

Anesthesia Options

• Apply topical anesthetics as early as possible:
  • Lidocaine-epinephrine-tetracaine (LET) gel provides excellent wound anesthesia in 20-30 minutes 2
  • For children, LET gel is particularly useful to avoid general anesthesia 4
• For injectable anesthesia, use the following technique for minimal pain:
  • Buffer lidocaine with bicarbonate
  • Warm the lidocaine before injection
  • Inject slowly using a small-gauge needle 2

Wound Closure Technique

1. Primary closure is recommended for facial wounds (unlike other body areas) due to:

   • Better blood supply in the face
   • Cosmetic importance
   • Lower infection rates compared to other locations 1, 2

2. Closure technique options:

   • Suturing: Most common method for facial lacerations
     • Simple interrupted sutures for most facial wounds
     • Half-buried mattress (corner) sutures for irregular edges 5
     • Focus on accurate dermal approximation for strength 3
   • Tissue adhesives: Consider for small, low-tension wounds 5
   • Steri-Strips: For very small, superficial lacerations 2

3. Special anatomical considerations:

   • Eyelid: Requires careful examination of the eye and accurate alignment of lid margin 6
   • Nose: Check for septal hematoma; align nares and alar margins 6
   • Lip: Critical alignment of the vermillion border 6
   • Ear: Can often be closed in one layer 6

Antibiotic Management

• Preemptive antibiotics are recommended for facial wounds 1, 2
• Amoxicillin-clavulanate is recommended as it covers both aerobic and anaerobic bacteria 2

Post-Closure Care

• Apply white petrolatum ointment (as effective as antibiotic ointment) 5
• Keep wound clean and dry for first 24 hours
• Wetting the wound as early as 12 hours after repair does not increase infection risk 5
• Examine the wound 2-3 days after suture placement for signs of infection 3
• Consider early suture removal (3-5 days) for facial wounds to minimize scarring

Special Considerations

• For complex facial lacerations (involving specialized structures like eyelids, lips, or ears), consider referral to a specialized facial trauma team 7
• For pediatric patients, consider using topical anesthetics like LET gel to avoid general anesthesia 4
• In children, absorbable sutures should be considered for facial wounds to avoid the pain and anxiety of suture removal 2

Potential Complications

• Infection: Monitor for redness, swelling, and purulent discharge
• Poor cosmetic outcome: Can result from improper alignment, excessive tension, or delayed closure
• Damage to underlying structures: Nerves, ducts, or muscles may be injured and require specialized repair

By following this protocol for facial laceration management, you can optimize both functional and cosmetic outcomes while minimizing complications.